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Thursday, February 20, 2014

I said it was coming and it's here. Another toe into the waters also known as the mental health care system. For today, specifically, it's about managed care and the behavioral health companies that supposedly manage the care. For a great article about the detriment of managed care with issues surrounding mental health, Todd Essig wrote a superb piece for Forbes in August of 2012.

In other words, a stacked deck. In fact, we, the consumers, don't even get a card to hold, except of course, a worthless insurance ID card. For those who recall my recent issues with my medications, this is not about Health Republic. I'm still a fan.

The is about Blue Cross. Or as it's called in NYS, Empire Blue Cross Blue Shield. If I've gotten all of my facts correct, it's all part of Anthem. And if I've gotten the rest of my facts straight as it pertains to mental illness, just like medication management is outsourced, "behavioral health" is also outsourced. It would appear their chosen management company is Value Options.

Let's start with the terminology, shall we? Behavioral health?? Seriously?? I looked up the definition of behavior and all of its forms. Technically, mental illness could be classified as behavior within the broadest terms but to me, behavior is something about which we have a choice, something we might control, something we might learn or unlearn.

It is from that personal framework that I make this statement:

MENTAL ILLNESS IS NOT A BEHAVIORAL HEALTH ISSUE. IT'S A DISEASE OF AN ORGAN. SPECIFICALLY, THE BRAIN.

I challenge anyone to debate the issue. Any day, any where.

And now, the story. My first steps into the world of mental health advocacy.

A thought disorder was diagnosed. Thought disorder sounds so much better than the language currently in use.

Schizophrenia.

Instant stigma.

I'm learning much and I'm learning quickly. I'll spare you the facts and figures. I'll spare you the textbook version of how to achieve the best possible outcome when a person is diagnosed with a thought disorder. I'll simply say that the diagnosis generally follows a psychotic break. A person may be hearing voices or chatter in their head but not all thought disorders involve voices. At the most basic level, schizophrenia, a thought disorder, is a pattern of disorganized thinking. The disorganized thinking is debilitating unless it is properly treated. In some cases, people can go on to pursue careers in law, education, research. In other cases, the stress is too much under which circumstances, a more relaxed career path is necessary. In still other cases, work is simply not possible. (And in those cases, that does not mean, unfulfilled lives. There are other opportunities but that's for another day.)

Here's the thing. This is not a behavior that can be worked on by the individual afflicted with the thought disorder. It requires a team of professionals. Medication management and tweaking of meds is key. CBT and in some cases, even DBT may be used. Group therapy and individual therapy are still another part of the treatment protocol. And here's the other thing, for someone to have any chance at a so-called normal life, this type of care doesn't follow a specific timetable. Every brain is different, the treatment of these diseases is fluid, and it appears every component of the aforementioned care affords the best chance for that so called "normal life." Not one or two. This isn't a Chinese menu.

Unlike cancer, where there is a specific set of NCCN guidelines which, for the most part, are accepted as standard of care and employed in treatment, there's nothing but a murky mess when it comes to mental illness. For today, I'm sticking with just one mental illness, thought disorders. There are mood disorders, personality disorders and who knows what else. The big ones seem to be bipolar disorder, major depressive disorder and schizophrenia. These are umbrella terms and just like cancer can be Stage I through Stage 4, the severity of any mental illness falls under a spectrum.

To make matters worse, many symptoms are similar. Because of symptom overlap, it can take time for a good psychiatrist to peel away the layers and make an accurate diagnosis. The diagnosis guides the treatment. The importance of a correct diagnosis can not be overstated.

That's my second grade analysis of a highly complex issue. Since I'm new to all of this and I don't proclaim to understand too much of anything, rather than misspeak or come across as a know it all who is really an idiot, I'm keeping it as simple as possible.

The diagnosis is a thought disorder. Now what? Here's what........ coverage for care under our health insurance policies is handed off to the behavioral health management contractor to determine what level of care is appropriate, to provide prior authorization, from a desk a gazillion miles away, based upon the clinical evaluation of the doctors who are looking at the actual patient, ultimately, to say, "Sorry, THAT may be the best care, but THIS is where you have to go because THIS is one of our chosen facilities." AND, that presumes they even approve the care to begin with. A big presumption and one that we are often forced to fight for.

To add insult to injury, despite mental health parity laws, most of those laws don't apply to all (many, most) policies so treatment is generally restricted to 30 sessions with a psychiatrist and a therapist (combined) and if hospitalization is necessary, 30 days and out. Those are the annual limits. If you start the year off poorly, you'd better get your act together by March or April because the "benefits" are exhausted until the following January. IF you even have insurance, again another day for that part of the story.

Let me just say this. This System Sucks. It sucks: not a little bit, not somewhat, not a lot. The ENTIRE system sucks. Entirely.

My personal beef today? A NYS Empire Blue Cross policy is in effect. It has all of those stipulations and it has one extra just to make the situation a bit more impossible. As if that were even possible but alas..... Since the policy is a NY policy, treatment can only be in a NEW YORK facility. Empire is part of Anthem and Anthem has a national network of facilities. If there is no appropriate facility in the network within the state, technically, an appropriate facility either completely out of network or within their network but outside of the state should be made available for appropriate care. At least, that was the bill of goods that was sold along with this particular non ACA but ACA compliant policy.

Yeah. Good luck with that. New York, particularly Long Island, is a NIMBY area. Not In My Back Yard. Anything having to do with treatment for the the mentally ill, the attitude? Take it elsewhere. The closest appropriate facility, in this case, is in Connecticut. To be precise, Danbury, CT which is about 5 miles from the NY border and ten miles from the town of Brewster in NY where this is all playing out. Can't cross the state line even thought the Danbury facility is IN the Value Options network and there is nothing comparable to afford proper care. And, a quick wiki search reads as follows: Danbury is located within the NYC Metropolitan area. Add that to the list of "it's a felony if you cross state lines" .... being mentally ill ... the latest felony.

Yes, I've done my homework on the benefits and I'm ready to throw down for a fight. But, I find it horribly distasteful that I should have to be involved in this battle at all. It's a disgrace. It's appalling. It's disgusting. And, with HIPAA, unless the mentally ill cardholder has signed the necessary permission forms, those of us whose thoughts are (mostly) not disordered, can't even fight on their behalf. AGAIN, another day for yet another obstacle. Along with this for another day: Most of those with mental illnesses find themselves in jail, or homeless or if they are lucky enough, they have an endless well of money from which to draw for treatment.

Shame on Anthem, shame on Value Options, shame on every person who cries NIMBY, shame on us as a supposed civilized country when we are incapable of taking care of those among us who need it most.

Today, I hang my head in shame because I'm one little voice and there aren't enough little voices to band together and be that BIG voice demanding to be heard, demanding change. I will continue to use my little voice because it's the right thing to do.

THIS is something I will see change.

The stigma stops here.

PS:

Note to Value Options: For REAL, how can you post guidelines written in 2004 as the provider reference for treatment?? Reviewed in 2011 and again in 2013. By WHOM?? Do those guidelines contain ANY of the research published over the past 13 YEARS?

Note to everyone else: Who knows a better word for "Disgusted" because that really isn't capturing my feelings or even scratching the surface......

4 comments:

what a crock! each and every issue you reviewed is a travesty, and a big fat black mark on how this country regards mental illness, a disease of the brain. the triple pass the buck outsourcing of care, the lack of standards of care - yes, SHAME on it all. thank you for this post, for all the time and effort you have spent trying to raise awareness of a completely appalling and very sad system whose bottom line focuses on bucks, not disease. I will read the Forbes article in the hopes it will settle my stomach.

The lack of support in a hard situation is shocking. I hate what I read at times around care. If any one can get change it is you - but I'm still appalled that it is necessary. Imagine those who didn't have the support around them. Terrible.

I've been through hell with insurance DURING my time in facility, which made it kind of hard to get well. I despise the immorality of our government allowing only the rich to afford treatment & the rest of us to suffer.

Originally in the later part of the Middle Ages, insane asylums were built to remove the harassment ill people from the streets. These unfortunate people were feared and viewed with horror by most of the population of the time.